Claire* is a 41 year-old divorced woman with Type 2 diabetes and hypertension. With a limited-flexibility work schedule, she struggles to manage doctor’s appointments for herself, her two small children, and her chronically ill mother who lives with Claire. She is neither sure of what help she needs nor how to get it.
The change comes when her primary care doctor connects her with a care coordination team that explores Claire’s daily challenges and anticipates their impact on her health conditions. She begins Saturday-morning group visits with others who have diabetes, and receives assistance such as grocery-selection help from the nutritionist on the care team. They also help connect her with social services for her mother, so Claire can focus more on her own health.
Still falling short of her goals, her doctor consults with a cardiologist colleague. A shared care plan recommendation is developed offline and without requiring Claire to visit the cardiologist. The plan includes a Saturday walking club that occurs after the diabetes group visits. She can bring her kids along, and participants in the club enjoy “competing” and encouraging each other. Claire downloads data from digital pedometers to a log directly accessible to her care team. More progress is made.
Going forward, Claire knows that her care team will help anticipate her long-term needs, not just react to the adverse effects of her conditions.
Our path to the proactive model
Claire is not an actual patient, but her type of situation and need are very real. Everyone at Providence will have a role to play as we move forward with development of proactive care models. Alignment of our clinical, administrative and shared services caregivers is critical to providing value-based, connected care across each person’s lifespan.
Our strategy is to support and build on the initiatives already in place, creating a web of interconnected people, programs, support, technology tools, and information.
Karen Boudreau, M.D., our new vice president of care management and coordination, is leading this effort.
"We will work to build basic proactive care models, then identify the variations needed for specific communities we serve,” Dr. Boudreau explains. “Take diabetes, for example. The components of care for a patient in California and a patient in Alaska are very similar, but resources, contractual requirements and cultural factors often vary from region to region. This means that we’ll need to develop a set of variations on the basic model to meet the needs of specific communities.”
The focus for the remainder of 2016 will be on assessment of this challenge and creation of a road map.
Care management aligns with population health
Care management across the industry is evolving to be more focused on the total health of patients and groups – from wellness management and follow-up for patients with cancer in complete remission to identifying people with hypertension who aren’t having their blood pressure checked frequently enough.
As we identify the needs of specific populations -- by type of illness/condition, by geographic community, or by other factors – we’ll discover how to better serve our communities. We will enhance our patient’s total experience, and by working together with them to anticipate and manage their needs in between visits, we can minimize both overuse and underuse of services/visits.
Many innovative initiatives are already underway here at Providence. For example, Physician Services is rolling out the Proactive Care Gap Outreach program across our regions, closing care gaps with the help of a centralized team and automated outreach processes.
As a health care industry, consider where we’ve been and where we’re headed.
- Reactive - It was simple for centuries: people typically only saw a doctor when symptoms indicated they needed one.
- Preventive - Increased patient education and preventive tests, driven by primary care physicians and other providers, represented a major step forward in recent decades.
- Anticipatory - This is the new frontier. For individuals, and for whole populations, we need to anticipate issues and proactively interact with our patients who have chronic illnesses, as well as those we have treated and cured or who are simply at high risk. Identifying gaps in care and reaching out builds healthier communities, one patient at a time.
In this light, we see just how deep and durable our Providence promise is – know me, care for me, ease my way. It encompasses a health continuum that includes healthy living, prevention, diagnosis, treatment, recovery, home care and end-of-life care.
*Claire is a hypothetical patient.